Section 2: Getting Your Diagnosis
So you have some of the symptoms we discussed at the end of Section 1 and you book an appointment with your GP in the hopes of finding out what’s wrong and perhaps getting a diagnosis.
Both Debra’s journey and Jean’s show that there is no one way that a person will present to their GP with COPD. Symptoms are often subtle and do not add up to much taken individually. Your GP will be looking for trends over time. This is why having a relationship with your GP and practice nurse is so important.
Your GP Visit
This section written by contributor Dr Kylie Vannaman
During your appointment your GP will “take your history” by asking questions that revolve around what brought you in to see your GP on this particular day:
- What are your symptoms?
These might be shortness of breath, cough, sputum production, recurrent chest infections, wheezing or the sensation of chest tightness.
- Does your shortness of breath worsen with your daily activities? Do you wake up suddenly short of breath at night (paroxysmal nocturnal dyspnoea)?
How severe these are can be used to track if symptoms are getting better or worse. Waking up suddenly at night short of breath can be caused by several conditions that affect the heart and lungs, not just COPD.
- When did the symptoms start? Do they come and go? What makes them worse/better?
Your symptoms may indicate COPD or something else.
Asthma generally starts in early life and symptoms vary daily, often disappearing completely between attacks.
If symptoms did not start until adulthood and developed gradually, COPD is more likely, but there is certainly a lot of overlap.
Severe forms of scarring of the smaller airways (bronchiolitis) can occur in young, non-smokers and is sometimes associated with rheumatoid arthritis. Symptoms mimic COPD.
If someone has recently had fevers, chills or body aches, they may have acute influenza, bronchitis or pneumonia.
Often people cannot recall when their symptoms started as they’ve been so gradual, however, sometimes there will be, like Jean, a sense of “I never really felt quite right after that bout of bronchitis I had a few years ago”…
- Do you smoke or have you in the past?
If a person is over the age of 50, has a history of tobacco smoking and/or exposure to other lung irritants (second-hand smoke, chemicals, fumes or other work-related or hobby exposures), the risk of COPD is greater.
- What other medical issues do you have? Does anything run in your family / whanau?
If there is a history of heart disease or congestive heart failure, the symptoms could be cardiac related.
Allergies, eczema and asthma are common together.
- Have you been exposed to tuberculosis?
Some of the symptoms of TB (tuberculosis) can mimic COPD including persistent cough, thick sputum and difficulty breathing.
Your GP will then usually examine you or may do this at the same time as asking questions.
- Temperature, pulse, breaths per minute and blood pressure will be checked.
- Oxygen-saturation (pulse oximetry) may also be checked by using a non-painful little clip on your finger.
- Eyes, nose, throat and ears will be examined for any sign of infection.
- Chest will be examined to listen to heart and lungs.
- Wheeze can result from tightened small airways found in asthma, bronchitis, bronchiolitis and COPD.
- Coarse breath sounds can indicate an infection or fluid in the lungs depending on where and how severe.
- Crackles, usually at the bases of the lungs generally represents fluid in the lungs either from infection or fluid overload from an overworked heart. Crackles can also be caused when the tiny air sacs (alveoli) at the far ends of the airways are collapsed shut due to shallow breathing, chronic lung damage or infection.
- Neck. If there is some degree of heart failure, the jugular veins that run up each side of the neck can become larger due to fluid backing up from the heart.
- Assess whether the abdominal or rib muscles are being used to help breathe (normally the diaphragm is strong enough to do it on its own).
- Check for any hernias or fluid in the abdomen that might be pushing up on the lungs making it more difficult to breathe.
- Hands / legs / feet. Check for any swelling, especially in the feet and lower legs, which could mean the heart is pumping harder or suffering from some degree of heart failure.
This section written by contributor Dr Kylie Vannaman
Once your history has been taken and your examination is complete, there may be a variety of tests that need to be done. These will be either requested urgently on the day or over the following weeks to determine the cause of your symptoms. Some tests are done to confirm a diagnosis of COPD and some are done to rule out other possibilities.
Initial tests may include:
- An ECG (Electrocardiogram) and a blood test may be ordered to rule out a heart attack or acute congestive heart failure.
- A chest x-ray may be needed to determine whether there is an active lung infection or fluid in the lungs that may represent heart failure.
Lung Function Tests
Once your acute symptoms are stable, i.e. your chest infection or other episode has settled down, further testing will help determine whether COPD is the cause of your symptoms. Spirometry is the most important initial test in diagnosing COPD, but is not very accurate during an acute illness, which means you may need to return to see your GP about 6 weeks after you recover from an acute illness before having this testing done. Even if you recover and feel well again it is very important to keep your follow up appointment if your GP asked for one. Not keeping a follow up appointment may mean your COPD goes on undiagnosed and makes it harder for your GP to treat you appropriately.
Peak FlowYour doctor or nurse may recommend that you monitor your peak flow (maximum peak of blowing out) with a small device, called a peak flow meter that you can use at home. This shows how tight your airways are at any given time. It often takes a bit of practice to get the hang of this test, but is painless and otherwise fairly easy to operate.
This kind of monitor can be useful to help differentiate between whether your symptoms are caused by asthma or COPD. In asthma, you will tend to notice that your peak flow readings fluctuate throughout the day, whereas in COPD the readings stay fairly constant.
SpirometrySimilar to a peak flow test, spirometry involves blowing into a handheld mouthpiece, but takes a bit more practice. Your practice nurse or respiratory technician will lead you through this and demonstrate the correct technique.
Spirometry testing is often done both before and after the use of a short-acting bronchodilator (such as salbutamol).
The standard spirometry process is to breathe in as far as you can (take a maximal deep inspiration) followed by breathing out as fast and as hard as you can (maximum forced exhalation). Several measurements can be read from this blow:
- FVC – Forced Vital Capacity
The total volume of air that you can forcibly exhale in one breath.
- FEV1 – Forced Expiratory Volume in One Second
The volume of air that you are able to exhale in the first second of forced expiration.
- FEV1 / FVC
The ratio of FEV1 to FVC expressed as a fraction (previously this was expressed as a percentage).
The values of FEV1 and FVC are measured in litres and are also expressed as a percentage of the predicted values for the person being tested.
People with normal lungs can exhale most of the air in their lungs in one second. When lungs are obstructed (as in COPD), it takes longer to blow all the air out.
In COPD the three measurements (FVC, FEV1 and FEV1/FVC) are decreased. However in early COPD the FVC may often be normal.
COPD is diagnosed when you have a FEV1/FVC ratio of less than 70% and an FEV1 of less than 80% of expected (based on age, gender, height and ethnicity). Your GP or Respiratory Specialist will talk to you about your results if you have this test.
Spirometry testing is very useful in both diagnosis and monitoring of COPD and should be done at regular intervals (but not during acute illness) for those suspected of and living with COPD to help guide treatment.
Other tests may be used to help rule out other causes of breathing difficulties such as:
- A chest x-ray or CT scan to look for infection or other abnormalities
- An ECG or echocardiogram to check for heart problems, or
- Allergy testing.
Sometimes people can have overlapping diagnoses that lead to breathing problems and you may be sent to the Respiratory Specialist for other tests such as:
- Lung diffusion testing which involves breathing in a gas for an enhanced version of spirometry.
- Bronchoscopy a tiny tube and camera are inserted into the airways to look for abnormalities.
- V/Q scan a nuclear isotope scan that compares ventilation of the lung versus perfusion (blood flow through the lung).
- Sleep study.
- Specialized blood tests.
Although people are often treated before COPD is confirmed, accurate diagnosis is important as some treatment options are only fully funded in New Zealand if specific criteria (spirometry measures) are met. Thus it is important that you help your GP and healthcare team by keeping your appointments for any tests that are organised for you.
Stages of COPD
You may be told by your GP or Specialist that you are COPD Stage 1-4. These stages help to classify COPD based on the level of airflow obstruction found on spirometry and are classified by GOLD (The Global Initiative for Chronic Obstructive Lung Disease).
|Stage 0||At risk||FEV1/FCV<0.70||FEV1 > 80% normal|
|Stage I||Mild COPD||FEV1/FVC<0.70||FEV1 ≥ 80% normal|
|Stage II||Moderate COPD||FEV1/FVC<0.70||FEV1 50-79% normal|
|Stage III||Severe COPD||FEV1/FVC<0.70||FEV1 30-49% normal|
|Stage IV||Very Severe COPD||FEV1/FVC<0.70||FEV1 <30% normal, or <50% normal with chronic respiratory failure present|
What is COPD?
Once you have your diagnosis of COPD don’t think you are on your own. In 2004 the World Health Organisation estimated that 64 million people worldwide had COPD . Here, in New Zealand, COPD affects an estimated 200,000 people or 15% of the adult population over the age of 45 years .
One of your first questions is probably, “What is COPD?” COPD is an umbrella term for the diseases emphysema, chronic bronchitis and chronic asthma. A person with COPD has one or more of these diseases. All of these are diseases where the airways are partially blocked and the lungs are damaged making it difficult to breath.
In Emphysema, inflammation of the air sacs (alveoli) causes them to lose their elasticity. The walls of the individual air sacs break down and air sacs join up together forming one large space rather than the normal “bunch of grapes” appearance. With one large structure there is less surface area for gas exchange resulting in low levels of oxygen in the blood (hypoxaemia) and the tissues of the body (hypoxia).
In asthma narrowing of the flow of air is due to inflammation which causes thickening of the walls of the airways. Unlike normal asthma where the narrowing of the airways is reversible with medication, in long standing chronic asthma, this inflammation can lead to scarring and the airways become remodelled, making them less able to return to normal functionality.
With Chronic Bronchitis the large and medium sized airways (bronchi) are inflamed and produce a lot of mucous. This leads to coughing and difficulty getting air in and out of the lungs.
Alpha-1 Antitrypsin Deficiency
Alpha-1 Antitrypsin Deficiency (Alpha-1) is the most common known genetic risk factor for emphysema. For this reason, it is often referred to as “genetic COPD.” Alpha-1 can cause both lung and liver disease though lung disease is the most common. Up to 3% of all people diagnosed with COPD may have Alpha-1.
Alpha-1 is often misdiagnosed as asthma or smoking-related COPD. Alpha-1 cannot be diagnosed definitively based on a patient’s medical history Nor physical examination and diagnosis is made by a simple blood test.
In 2003, the American Thoracic Society (ATS) and the European Respiratory Society (ERS) jointly released the ATS/ERS Consensus Document, providing new standard guidelines for testing those with the following at-risk factors:
- Symptomatic adults with emphysema, COPD, or asthma that can’t be completely treated with bronchodilators.
- Individuals with no symptoms (asymptomatic) but with persistent obstruction on pulmonary function tests who have identifiable risk factors such as cigarette smoking, occupational exposure, etc.
Your GP should be able to arrange this blood test if appropriate.
|Further information about Alpha-1 can be found at http://alpha-1foundation.org.|